HomeMy WebLinkAbout2871 . 1g12,~
Declaratio~ ot Oon~icile a~d Citizenship
TO THE STATE AND COUNTY TAX ASSESSOR,
Sj. LUCIE ~OUNTY, FIORIDA:
This is my decla~ation of ~omicile and Citizenship in the State of Florida that 1 am filing this day in atcordance and
in ao~formity with Chapter 222, Section 222.17, Florida Statutes.
1 was forme~ly a teqal res~de~! of -Carter_ Cou~t,~____!_____~ Tennessee
. (Ciy) (State)
and 1 resided at Route_.~? B1iZabt!thti; Howevef 1 havechanged my domicile
(Street a~d Number)
to and am and have been a bona fide recident of the State of Florida since 23rd day of
Decemb~__~ , t9
66 , and I ~eside at 1013 South 12th Street
(Street and Number)
FORT PI~CE, SAINT lUC1E COUNTY, RORIDA
and this statement is to be taken as my declarotion of ~citize~ship, actual legal residence and donicile in the State of Horida.
(Insert here any pe~tinent facts, such as sale of p~operty or business, or ~elinquishment of cmployment
at former domicite, removal of family to new domicile, purchase of home, etc.)
Ad~inistrator of the Fort Pie~ce
M~m~rial Hospital~
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I' ROGER PO~TRAS i
Cu,rR~( CIRCUIT COU~ - ;
1
1 RJR~ii~R CERTIFY that 1 will oomply with all other requi~ements of a legal resident ~f this State.
I FURTHER CERTI~If 'fiat 1 have no intention to retum to my forme~ domicile, and 1 intend to remain in ~ORT
PIERCE, SAINT LUCIE COUNTY, FIORIDA, pe~manently. ~
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(Name)
1013 South-12th Streets
~ (Address)
Sworn to and subscribed before me this 29tb day of Decembe r ~ 19 66_
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ROGHE POITRAS • •
a.iww:T L4URT ~;~~:.=•~i~j= _ _ Notary Publit
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gy = V • - ~ ' ~ = My Commiuion expires
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(To b~ execvt~d in dupficah~'~i~.~' Cl~rlc Circuit Court, and dupticsf~ with Tax A~or.)
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